Injury-stricken physical shock absorbers
About
The importance of the meniscus in the knee joint is best shown by the fact that osteoarthritis (cartilage damage) after meniscectomy (partial or complete removal of the meniscus) is much more common than in the healthy knee which has not undergone surgery.
Knee menisci are two elastic, crescent, connective-cartilaginous structures that achieve alignment of the femoral and tibial articular surfaces. The menisci are made up of 70 per cent water and 30 per cent of organic matter, which mostly consists of connective collagen fibres (75 per cent). In surface layers collagen fibres are placed radially, in the deep layer they are placed longitudinally or circularly, and in peripheral structures, they form a network. Such arrangement of collagen fibres, their waviness and longitudinal twirl provide strength and elasticity to menisci. At birth, the fibres are fully vascularised, but by the age of ten, the vascularisation is reduced to 10 to 30 per cent of the peripherals (the section next to the shell) of both menisci.
Thanks to their shape and structure, menisci have important functions in the knee joint. They disperse the load of the entire articular surface of the knee joint, absorb shock, stabilize the ankle, facilitate sliding, (joint movement), improve lubrication of joints, and consequently improve the cartilage nutrition, prevent excessive protrusion and have a proprioceptive role (send feedback to the brain). They overtake about 50 per cent of the load, which is transmitted through the knee joint in extension and about 85 per cent in flexion of the knee. In case of partial or complete removal of the meniscus, the contact surface is reduced and the load increases:
- a partial meniscectomy (only 10 per cent of the meniscus) – results in a 65 per cent of load increase at the point of contact,
- a removal of the medial meniscus – results in 50 to 70percent of contact area reduction and an increase of the load at the point of contact by 100 per cent
- a complete lateral meniscectomy – leads to a 40-50 per cent smaller contact area and as many as 200 to 300 per cent larger load at the point of contact.
The function of an intact meniscus is extremely important to preserve the cartilage covering and knee function, i.e. to prevent or to slow down the occurrence of osteoarthritis.
Meniscus injuries are among the most frequent injuries to the knee joint and comprise about 75 per cent of the intra-articular knee pathology. They are a consequence of degeneration or trauma, or a combination thereof. A meniscus injury usually occurs by rotation mechanism in a mild flexion. An external rotation mechanism of the lower leg injures the medial meniscus, and an external rotation injures the lateral meniscus. The medial meniscus, especially its posterior horn is four times more frequently injured than the lateral. It is not uncommon that the same mechanism causes knee ligament injuries, as well as cartilage injuries.
Usually, an examination is sufficient to diagnose the injury
A rupture of the meniscus may be transversal, horizontal, longitudinal, inclined, or a combination thereof. In case of a longer longitudinal rupture, a free part of the meniscus may “slip” into articulate bodies and block the knee, which, due to that condition, cannot be stretched out. Along with the blockage, other clinical symptoms of a ruptured meniscus are pain at the joint cavity level, slight swelling of the knee joint, and a sense of instability may be present as well.
Candidate
Meniscal damages are among the most frequent injuries to the knee joint and make up about 75 per cent of interarticular knee pathology.
Preparation
The diagnosis of a ruptured meniscus is set up by taking of medical history, which is often typical, and a physical examination, which consists of a series of specific, usually not painful, tests. The tests can be supplemented by magnetic resonance imaging, but only upon examination by an orthopaedist or traumatologist. It is recommended to carry out a native radiographic image of the knee.
Treatment
The development of arthroscopic techniques and other technical requirements set up the grounds for a minimally invasive treatment of a ruptured meniscus. The first arthroscopic suture was performed by Hiroshi Ikeuchi in 1969. Over time, this method of treatment has become a widely accepted method, so today the treatment of a ruptured meniscus consists of an arthroscopic meniscectomy or a meniscal suture. Meniscectomy This treatment method means that the knee joint is not opened, but an arthroscope (camera) is inserted through a small opening on one side and a specially designed instrument is inserted on the other side, so only the damaged part of the meniscus is removed. If it is in any way possible, the injured part of the meniscus is sutured thus preserving its integrity, which is favourable for the subsequent function of the knee joint. For many years the only method of treatment was a partial or total meniscectomy, but soon it was realized that the meniscus does not regenerate, it can only be repaired and can grow up to one-third of its normal volume, which is not sufficient for a normal function, thus causing early degenerative changes of the knee. All this leads to the conclusion that meniscectomy should be avoided whenever possible, and if it needs to be done, it is recommended to be as minimal as possible, i.e. to remove only a part of the ruptured meniscus. Meniscus sutures Compared to meniscectomy, suturing is a technically more demanding procedure which prolongs surgery and requires the knowledge of several different meniscus suturing techniques, and assumes the availability of operating instruments as a technical prerequisite. Unfortunately, not all meniscus ruptures can be sutured. To suture a ruptured meniscus it is necessary to know its blood supply. Since the blood supply is necessary for the healing of a ruptured meniscus, the most suitable for suturing is the peripheral meniscus area, which has the best blood supply. When deciding on meniscus suturing it is important to take into account the type of rupture. Suturing is most appropriate for longitudinal ruptures in the vascular rupture zone and the meniscus and cap joint. This indication is questionable in the case of transversal, horizontal ruptures, ruptures in flap shapes, and various degenerative ruptures. The quality of a meniscus is also important, so it must not be torn or degeneratively altered. Younger patients are most suitable for meniscus suturing (younger than 40, and according to some authors, 50) with a fresh meniscus injury (preferably up to two months old), without injury of cruciate ligaments or with the reconstruction of the anterior cruciate ligament, in case of its rupture. The practice has shown that only 10 per cent of the damaged menisci meet the above criteria for suturing.
Result
There is a significant difference in the rehabilitation process after meniscectomy or meniscal suturing. The rehabilitation process after a meniscectomy is quick, typically with minimum pain, and patients can quickly return to full work and sports activities, usually after three to four weeks. But for a sutured meniscus the patient must be motivated, as the postoperative rehabilitation lasts longer. Due to this prolonged healing, many professional athletes do not opt for this treatment. The rehabilitation after meniscus suturing consists of limiting flexion and preventing rotation of the knee.
Precautions
In the first two weeks, the movement is limited by orthosis to 0/30°, followed by a 0/50° range in the third week, and after that 0/90°. After four weeks full flexion is gradually allowed, but squatting and kneeling are forbidden. Walking is permitted immediately after surgery. Rotations of the knee, such as jumping, landing and running with the directional change are forbidden for three months after the surgery. Running without a change of direction is allowed after three months, and a contact sport with rotation six months after the procedure. If there was the reconstruction of the anterior cruciate ligament performed along with the meniscus suturing, then the rehabilitation process does not differ, concerning accelerated rehabilitation after the reconstruction of the anterior cruciate ligament and an orthosis is not required.
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F.A.Q.
The knee menisci are two C-shaped pieces of cartilage located between the thigh bone (femur) and the shin bone (tibia) in the knee joint. They act as shock absorbers and help with load distribution and stability.
Meniscus injuries often occur during activities that involve twisting or direct impact to the knee, such as sports-related activities or sudden stops and turns. They can also occur due to age-related degeneration and wear and tear.
Symptoms of a meniscus injury can include pain, swelling, stiffness, limited range of motion, a popping or clicking sensation in the knee, and difficulty fully straightening or bending the knee.
Meniscus injuries are typically diagnosed through a combination of a physical examination, medical history review, and imaging tests such as magnetic resonance imaging (MRI). These tests help assess the location, extent, and type of meniscus injury.
Some meniscus tears have the potential to heal on their own, particularly in cases where the tear is located in the outer portion of the meniscus with a good blood supply. However, the healing potential depends on various factors, and larger or complex tears often require surgical intervention.
Treatment options for a meniscus injury depend on factors such as the size, location, and type of tear, as well as the individual's age and activity level. Non-surgical treatments may include rest, ice, physical therapy, and anti-inflammatory medications. Surgical options may include meniscus repair or meniscectomy (partial meniscus removal).
Recovery from meniscus surgery can vary depending on the type and extent of the surgery performed, as well as individual factors. Generally, recovery may take several weeks to a few months. Physical therapy and rehabilitation are crucial in regaining strength, range of motion, and function in the knee.
Many individuals are able to return to sports and physical activities after a meniscus injury and appropriate treatment. The timeline for return to sports depends on various factors, including the extent of the injury, type of surgery, rehabilitation progress, and guidance from the healthcare team.
If left untreated or not properly rehabilitated, a meniscus injury can lead to long-term complications such as persistent pain, knee instability, and an increased risk of developing osteoarthritis in the affected knee joint. Timely and appropriate treatment can help minimize the risk of such complications.
While it's not always possible to prevent meniscus injuries, certain measures can help reduce the risk. These include maintaining strong and flexible leg muscles through regular exercise, using proper techniques during physical activities, wearing appropriate footwear, and avoiding sudden, high-impact movements that place excessive stress on the knee joint.
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